(REPRINTED WITH ADOPTED AMENDMENTS)

 

Senate Bill No. 99–Senator O’Connell (by request)

 

February 12, 2001

____________

 

Referred to Committee on Commerce and Labor

 

SUMMARY—Makes various changes to provisions governing health insurance. (BDR 57‑132)

 

FISCAL NOTE:  Effect on Local Government: No.

                             Effect on the State: No.

 

~

 

EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted.

 

AN ACT relating to insurance; revising provisions governing the prompt payment by insurers of approved claims to providers of health care; revising the rate of interest applicable to the late payment of such claims; prohibiting the assessment of fees against providers of health care to be included on a list of providers of health care; establishing an administrative fine against insurers who do not substantially comply with the provisions requiring prompt payment of approved claims to providers of health care; allowing an employee who is injured or who contracts an occupational disease outside this state to receive compensation from the uninsured employers’ claim fund under certain circumstances; and providing other matters properly relating thereto.

 

THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN

SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:

 

1-1    Section 1. NRS 679B.138 is hereby amended to read as follows:

1-2    679B.138  1.  The commissioner shall adopt regulations which require

1-3  the use of uniform claim forms and billing codes and the ability to make

1-4  compatible electronic data transfers for all insurers and administrators

1-5  authorized to conduct business in this state relating to a health care plan or

1-6  health insurance or providing or arranging for the provision of health care

1-7  services, including, without limitation, an insurer that issues a policy of

1-8  health insurance, an insurer that issues a policy of group health insurance, a

1-9  carrier serving small employers, a fraternal benefit society, a hospital or

1-10  medical service corporation, a health maintenance organization, a plan for

1-11  dental care and a prepaid limited health service organization. The

1-12  regulations must include, without limitation, a uniform billing format to

1-13  be used for the submission of claims to such insurers and administrators.

1-14    2.  As used in this section:

1-15    (a) “Administrator” has the meaning ascribed to it in NRS 683A.025.

2-1    (b) “Health care plan” means a policy, contract, certificate or agreement

2-2  offered or issued by an insurer to provide, deliver, arrange for, pay for or

2-3  reimburse any of the costs of health care services.

2-4    Sec. 1.5.  NRS 683A.0879 is hereby amended to read as follows:

2-5    683A.0879  1.  Except as otherwise provided in subsection 2, an

2-6  administrator shall approve or deny a claim relating to health insurance

2-7  coverage within 30 days after the administrator receives the claim. If the

2-8  claim is approved, the administrator shall pay the claim within 30 days

2-9  after it is approved. [If] Except as otherwise provided in this section, if the

2-10  approved claim is not paid within that period, the administrator shall pay

2-11  interest on the claim at [the] a rate of interest [established pursuant to NRS

2-12  99.040 unless a different rate of interest is established pursuant to an

2-13  express written contract between the administrator and the provider of

2-14  health care.] equal to the prime rate at the largest bank in Nevada, as

2-15  ascertained by the commissioner of financial institutions, on January 1

2-16  or July 1, as the case may be, immediately preceding the date on which

2-17  the payment was due, plus 6 percent. The interest must be calculated from

2-18  30 days after the date on which the claim is approved until the date on

2-19  which the claim is paid.

2-20    2.  If the administrator requires additional information to determine

2-21  whether to approve or deny the claim, he shall notify the claimant of his

2-22  request for the additional information within 20 days after he receives the

2-23  claim. The administrator shall notify the provider of health care of all the

2-24  specific reasons for the delay in approving or denying the claim. The

2-25  administrator shall approve or deny the claim within 30 days after

2-26  receiving the additional information. If the claim is approved, the

2-27  administrator shall pay the claim within 30 days after he receives the

2-28  additional information. If the approved claim is not paid within that period,

2-29  the administrator shall pay interest on the claim in the manner prescribed in

2-30  subsection 1.

2-31    3.  An administrator shall not request a claimant to resubmit

2-32  information that the claimant has already provided to the administrator,

2-33  unless the administrator provides a legitimate reason for the request and the

2-34  purpose of the request is not to delay the payment of the claim, harass the

2-35  claimant or discourage the filing of claims.

2-36    4.  An administrator shall not pay only part of a claim that has been

2-37  approved and is fully payable.

2-38    5.  A court shall award costs and reasonable attorney’s fees to the

2-39  prevailing party in an action brought pursuant to this section.

2-40    6.  The payment of interest provided for in this section for the late

2-41  payment of an approved claim may be waived only if the payment was

2-42  delayed because of an act of God or another cause beyond the control of

2-43  the administrator.

2-44    7.  The commissioner may require an administrator to provide

2-45  evidence which demonstrates that the administrator has substantially

2-46  complied with the requirements set forth in this section, including,

2-47  without limitation, payment within 30 days of at least 95 percent of

2-48  approved claims or at least 90 percent of the total dollar amount for

2-49  approved claims. If the commissioner determines that an administrator is

3-1  not in substantial compliance with the requirements set forth in this

3-2  section, the commissioner may require the administrator to pay an

3-3  administrative fine in an amount to be determined by the commissioner.

3-4    Sec. 2.  NRS 689A.035 is hereby amended to read as follows:

3-5    689A.035  An insurer [may] shall not charge a provider of health care

3-6  a fee to include the name of the provider on a list of providers of health

3-7  care given by the insurer to its insureds. [The amount of the fee must be

3-8  reasonable and must not exceed an amount that is directly related to the

3-9  administrative costs of the insurer to include the provider on the list.]

3-10    Sec. 3.  NRS 689A.410 is hereby amended to read as follows:

3-11    689A.410  1.  Except as otherwise provided in subsection 2, an insurer

3-12  shall approve or deny a claim relating to a policy of health insurance within

3-13  30 days after the insurer receives the claim. If the claim is approved, the

3-14  insurer shall pay the claim within 30 days after it is approved. [If] Except

3-15  as otherwise provided in this section, if the approved claim is not paid

3-16  within that period, the insurer shall pay interest on the claim at [the] a rate

3-17  of interest [established pursuant to NRS 99.040 unless a different rate of

3-18  interest is established pursuant to an express written contract between the

3-19  insurer and the provider of health care.] equal to the prime rate at the

3-20  largest bank in Nevada, as ascertained by the commissioner of financial

3-21  institutions, on January 1 or July 1, as the case may be, immediately

3-22  preceding the date on which the payment was due, plus 6 percent. The

3-23  interest must be calculated from 30 days after the date on which the claim

3-24  is approved until the date on which the claim is paid.

3-25    2.  If the insurer requires additional information to determine whether

3-26  to approve or deny the claim, it shall notify the claimant of its request for

3-27  the additional information within 20 days after it receives the claim. The

3-28  insurer shall notify the provider of health care of all the specific reasons for

3-29  the delay in approving or denying the claim. The insurer shall approve or

3-30  deny the claim within 30 days after receiving the additional information. If

3-31  the claim is approved, the insurer shall pay the claim within 30 days after it

3-32  receives the additional information. If the approved claim is not paid within

3-33  that period, the insurer shall pay interest on the claim in the manner

3-34  prescribed in subsection 1.

3-35    3.  An insurer shall not request a claimant to resubmit information that

3-36  the claimant has already provided to the insurer, unless the insurer provides

3-37  a legitimate reason for the request and the purpose of the request is not to

3-38  delay the payment of the claim, harass the claimant or discourage the filing

3-39  of claims.

3-40    4.  An insurer shall not pay only part of a claim that has been approved

3-41  and is fully payable.

3-42    5.  A court shall award costs and reasonable attorney’s fees to the

3-43  prevailing party in an action brought pursuant to this section.

3-44    6.  The payment of interest provided for in this section for the late

3-45  payment of an approved claim may be waived only if the payment was

3-46  delayed because of an act of God or another cause beyond the control of

3-47  the insurer.

3-48    7.  The commissioner may require an insurer to provide evidence

3-49  which demonstrates that the insurer has substantially complied with the

4-1  requirements set forth in this section, including, without limitation,

4-2  payment within 30 days of at least 95 percent of approved claims or at

4-3  least 90 percent of the total dollar amount for approved claims. If the

4-4  commissioner determines that an insurer is not in substantial compliance

4-5  with the requirements set forth in this section, the commissioner may

4-6  require the insurer to pay an administrative fine in an amount to be

4-7  determined by the commissioner.

4-8    Sec. 4.  NRS 689B.015 is hereby amended to read as follows:

4-9    689B.015  An insurer that issues a policy of group health insurance

4-10  [may] shall not charge a provider of health care a fee to include the name

4-11  of the provider on a list of providers of health care given by the insurer to

4-12  its insureds. [The amount of the fee must be reasonable and must not

4-13  exceed an amount that is directly related to the administrative costs of the

4-14  insurer to include the provider on the list.]

4-15    Sec. 5.  NRS 689B.255 is hereby amended to read as follows:

4-16    689B.255  1.  Except as otherwise provided in subsection 2, an insurer

4-17  shall approve or deny a claim relating to a policy of group health insurance

4-18  or blanket insurance within 30 days after the insurer receives the claim. If

4-19  the claim is approved, the insurer shall pay the claim within 30 days after it

4-20  is approved. [If] Except as otherwise provided in this section, if the

4-21  approved claim is not paid within that period, the insurer shall pay interest

4-22  on the claim at [the] a rate of interest [established pursuant to NRS 99.040

4-23  unless a different rate of interest is established pursuant to an express

4-24  written contract between the insurer and the provider of health care.] equal

4-25  to the prime rate at the largest bank in Nevada, as ascertained by the

4-26  commissioner of financial institutions, on January 1 or July 1, as the

4-27  case may be, immediately preceding the date on which the payment was

4-28  due, plus 6 percent. The interest must be calculated from 30 days after the

4-29  date on which the claim is approved until the date on which the claim is

4-30  paid.

4-31    2.  If the insurer requires additional information to determine whether

4-32  to approve or deny the claim, it shall notify the claimant of its request for

4-33  the additional information within 20 days after it receives the claim. The

4-34  insurer shall notify the provider of health care of all the specific reasons for

4-35  the delay in approving or denying the claim. The insurer shall approve or

4-36  deny the claim within 30 days after receiving the additional information. If

4-37  the claim is approved, the insurer shall pay the claim within 30 days after it

4-38  receives the additional information. If the approved claim is not paid within

4-39  that period, the insurer shall pay interest on the claim in the manner

4-40  prescribed in subsection 1.

4-41    3.  An insurer shall not request a claimant to resubmit information that

4-42  the claimant has already provided to the insurer, unless the insurer provides

4-43  a legitimate reason for the request and the purpose of the request [in] is not

4-44  to delay the payment of the claim, harass the claimant or discourage the

4-45  filing of claims.

4-46    4.  An insurer shall not pay only part of a claim that has been approved

4-47  and is fully payable.

4-48    5.  A court shall award costs and reasonable attorney’s fees to the

4-49  prevailing party in an action brought pursuant to this section.

5-1    6.  The payment of interest provided for in this section for the late

5-2  payment of an approved claim may be waived only if the payment was

5-3  delayed because of an act of God or another cause beyond the control of

5-4  the insurer.

5-5    7.  The commissioner may require an insurer to provide evidence

5-6  which demonstrates that the insurer has substantially complied with the

5-7  requirements set forth in this section, including, without limitation,

5-8  payment within 30 days of at least 95 percent of approved claims or at

5-9  least 90 percent of the total dollar amount for approved claims. If the

5-10  commissioner determines that an insurer is not in substantial compliance

5-11  with the requirements set forth in this section, the commissioner may

5-12  require the insurer to pay an administrative fine in an amount to be

5-13  determined by the commissioner.

5-14    Sec. 6.  NRS 689C.435 is hereby amended to read as follows:

5-15    689C.435  A carrier serving small employers and a carrier that offers a

5-16  contract to a voluntary purchasing group [may] shall not charge a provider

5-17  of health care a fee to include the name of the provider on a list of

5-18  providers of health care given by the carrier to its insureds. [The amount of

5-19  the fee must be reasonable and must not exceed an amount that is directly

5-20  related to the administrative costs of the carrier to include the provider on

5-21  the list.]

5-22    Sec. 7.  NRS 689C.485 is hereby amended to read as follows:

5-23    689C.485  1.  Except as otherwise provided in subsection 2, a carrier

5-24  serving small employers and a carrier that offers a contract to a voluntary

5-25  purchasing group shall approve or deny a claim relating to a policy of

5-26  health insurance within 30 days after the carrier receives the claim. If the

5-27  claim is approved, the carrier shall pay the claim within 30 days after it is

5-28  approved. [If] Except as otherwise provided in this section, if the

5-29  approved claim is not paid within that period, the carrier shall pay interest

5-30  on the claim at [the] a rate of interest [established pursuant to NRS 99.040

5-31  unless a different rate of interest is established pursuant to an express

5-32  written contract between the carrier and the provider of health care.] equal

5-33  to the prime rate at the largest bank in Nevada, as ascertained by the

5-34  commissioner of financial institutions, on January 1 or July 1, as the

5-35  case may be, immediately preceding the date on which the payment was

5-36  due, plus 6 percent. The interest must be calculated from 30 days after the

5-37  date on which the claim is approved until the date on which the claim is

5-38  paid.

5-39    2.  If the carrier requires additional information to determine whether to

5-40  approve or deny the claim, it shall notify the claimant of its request for the

5-41  additional information within 20 days after it receives the claim. The

5-42  carrier shall notify the provider of health care of all the specific reasons for

5-43  the delay in approving or denying the claim. The carrier shall approve or

5-44  deny the claim within 30 days after receiving the additional information. If

5-45  the claim is approved, the carrier shall pay the claim within 30 days after it

5-46  receives the additional information. If the approved claim is not paid within

5-47  that period, the carrier shall pay interest on the claim in the manner

5-48  prescribed in subsection 1.

6-1    3.  A carrier shall not request a claimant to resubmit information that

6-2  the claimant has already provided to the carrier, unless the carrier provides

6-3  a legitimate reason for the request and the purpose of the request is not to

6-4  delay the payment of the claim, harass the claimant or discourage the filing

6-5  of claims.

6-6    4.  A carrier shall not pay only part of a claim that has been approved

6-7  and is fully payable.

6-8    5.  A court shall award costs and reasonable attorney’s fees to the

6-9  prevailing party in an action brought pursuant to this section.

6-10    6.  The payment of interest provided for in this section for the late

6-11  payment of an approved claim may be waived only if the payment was

6-12  delayed because of an act of God or another cause beyond the control of

6-13  the carrier.

6-14    7.  The commissioner may require a carrier to provide evidence

6-15  which demonstrates that the carrier has substantially complied with the

6-16  requirements set forth in this section, including, without limitation,

6-17  payment within 30 days of at least 95 percent of approved claims or at

6-18  least 90 percent of the total dollar amount for approved claims. If the

6-19  commissioner determines that a carrier is not in substantial compliance

6-20  with the requirements set forth in this section, the commissioner may

6-21  require the carrier to pay an administrative fine in an amount to be

6-22  determined by the commissioner.

6-23    Sec. 8.  NRS 695A.095 is hereby amended to read as follows:

6-24    695A.095  A society [may] shall not charge a provider of health care a

6-25  fee to include the name of the provider on a list of providers of health care

6-26  given by the society to its insureds. [The amount of the fee must be

6-27  reasonable and must not exceed an amount that is directly related to the

6-28  administrative costs of the society to include the provider on the list.]

6-29    Sec. 9.  NRS 695B.035 is hereby amended to read as follows:

6-30    695B.035  A corporation subject to the provisions of this chapter [may]

6-31  shall not charge a provider of health care a fee to include the name of the

6-32  provider on a list of providers of health care given by the corporation to its

6-33  insureds. [The amount of the fee must be reasonable and must not exceed

6-34  an amount that is directly related to the administrative costs of the

6-35  corporation to include the provider on the list.]

6-36    Sec. 10.  NRS 695B.2505 is hereby amended to read as follows:

6-37    695B.2505  1.  Except as otherwise provided in subsection 2, a

6-38  corporation subject to the provisions of this chapter shall approve or deny a

6-39  claim relating to a contract for dental, hospital or medical services within

6-40  30 days after the corporation receives the claim. If the claim is approved,

6-41  the corporation shall pay the claim within 30 days after it is approved. [If]

6-42  Except as otherwise provided in this section, if the approved claim is not

6-43  paid within that period, the corporation shall pay interest on the claim at

6-44  [the] a rate of interest [established pursuant to NRS 99.040 unless a

6-45  different rate of interest is established pursuant to an express written

6-46  contract between the corporation and the provider of health care.] equal to

6-47  the prime rate at the largest bank in Nevada, as ascertained by the

6-48  commissioner of financial institutions, on January 1 or July 1, as the

6-49  case may be, immediately preceding the date on which the payment was

7-1  due, plus 6 percent. The interest must be calculated from 30 days after the

7-2  date on which the claim is approved until the date on which the claim is

7-3  paid.

7-4    2.  If the corporation requires additional information to determine

7-5  whether to approve or deny the claim, it shall notify the claimant of its

7-6  request for the additional information within 20 days after it receives the

7-7  claim. The corporation shall notify the provider of dental, hospital or

7-8  medical services of all the specific reasons for the delay in approving or

7-9  denying the claim. The corporation shall approve or deny the claim within

7-10  30 days after receiving the additional information. If the claim is approved,

7-11  the corporation shall pay the claim within 30 days after it receives the

7-12  additional information. If the approved claim is not paid within that period,

7-13  the corporation shall pay interest on the claim in the manner prescribed in

7-14  subsection 1.

7-15    3.  A corporation shall not request a claimant to resubmit information

7-16  that the claimant has already provided to the corporation, unless the

7-17  corporation provides a legitimate reason for the request and the purpose of

7-18  the request is not to delay the payment of the claim, harass the claimant or

7-19  discourage the filing of claims.

7-20    4.  A corporation shall not pay only part of a claim that has been

7-21  approved and is fully payable.

7-22    5.  A court shall award costs and reasonable attorney’s fees to the

7-23  prevailing party in an action brought pursuant to this section.

7-24    6.  The payment of interest provided for in this section for the late

7-25  payment of an approved claim may be waived only if the payment was

7-26  delayed because of an act of God or another cause beyond the control of

7-27  the corporation.

7-28    7.  The commissioner may require a corporation to provide evidence

7-29  which demonstrates that the corporation has substantially complied with

7-30  the requirements set forth in this section, including, without limitation,

7-31  payment within 30 days of at least 95 percent of approved claims or at

7-32  least 90 percent of the total dollar amount for approved claims. If the

7-33  commissioner determines that a corporation is not in substantial

7-34  compliance with the requirements set forth in this section, the

7-35  commissioner may require the corporation to pay an administrative fine

7-36  in an amount to be determined by the commissioner.

7-37    Sec. 11.  Chapter 695C of NRS is hereby amended by adding thereto

7-38  the provisions set forth as sections 11.3 and 11.7 of this act.

7-39    Sec. 11.3.  1.  A health maintenance organization shall not:

7-40    (a) Enter into any contract or agreement, or make any other

7-41  arrangements, with a provider for the provision of health care; or

7-42    (b) Employ a provider pursuant to a contract, an agreement or any

7-43  other arrangement to provide health care,

7-44  unless the contract, agreement or other arrangement specifically

7-45  provides that the health maintenance organization and provider agree to

7-46  the schedule for the payment of claims set forth in NRS 695C.185.

7-47    2.  Any contract, agreement or other arrangement between a health

7-48  maintenance organization and a provider that is entered into or renewed

7-49  on or after October 1, 2001, that does not specifically include a provision

8-1  concerning the schedule for the payment of claims as required by

8-2  subsection 1 shall be deemed to conform with the requirements of

8-3  subsection 1 by operation of law.

8-4    Sec. 11.7.  Any contract or other agreement entered into or renewed

8-5  by a health maintenance organization on or after October 1, 2001:

8-6    1.  To provide health care services through managed care to

8-7  recipients of Medicaid under the state plan for Medicaid; or

8-8    2.  With the division of health care financing and policy of the

8-9  department of human resources to provide insurance pursuant to the

8-10  children’s health insurance program,

8-11  must require the health maintenance organization to pay interest to a

8-12  provider of health care services on a claim that is not paid within the

8-13  time provided in the contract or agreement at a rate of interest equal to

8-14  the prime rate at the largest bank in Nevada, as ascertained by the

8-15  commissioner of financial institutions, on January 1 or July 1, as the

8-16  case may be, immediately preceding the date on which the payment was

8-17  due, plus 6 percent. The interest must be calculated from 30 days after

8-18  the date on which the claim is approved until the date on which the claim

8-19  is paid.

8-20    Sec. 12.  NRS 695C.050 is hereby amended to read as follows:

8-21    695C.050  1.  Except as otherwise provided in this chapter or in

8-22  specific provisions of this Title, the provisions of this Title are not

8-23  applicable to any health maintenance organization granted a certificate of

8-24  authority under this chapter. This provision does not apply to an insurer

8-25  licensed and regulated pursuant to this Title except with respect to its

8-26  activities as a health maintenance organization authorized and regulated

8-27  pursuant to this chapter.

8-28    2.  Solicitation of enrollees by a health maintenance organization

8-29  granted a certificate of authority, or its representatives, must not be

8-30  construed to violate any provision of law relating to solicitation or

8-31  advertising by practitioners of a healing art.

8-32    3.  Any health maintenance organization authorized under this chapter

8-33  shall not be deemed to be practicing medicine and is exempt from the

8-34  provisions of chapter 630 of NRS.

8-35    4.  The provisions of NRS 695C.110, 695C.170 to 695C.200, inclusive,

8-36  [and] sections 19 and 20 of [this act,] Senate Bill No. 2 of this session,

8-37  section 11.3 of this act and NRS695C.250 and 695C.265 do not apply to a

8-38  health maintenance organization that provides health care services through

8-39  managed care to recipients of Medicaid under the state plan for Medicaid

8-40  or insurance pursuant to the children’s health insurance program pursuant

8-41  to a contract with the division of health care financing and policy of the

8-42  department of human resources. This subsection does not exempt a health

8-43  maintenance organization from any provision of this chapter for services

8-44  provided pursuant to any other contract.

8-45    5.  The provisions of NRS 695C.1694 and 695C.1695 apply to a health

8-46  maintenance organization that provides health care services through

8-47  managed care to recipients of Medicaid under the state plan for Medicaid.

 

 

9-1    Sec. 13.  NRS 695C.055 is hereby amended to read as follows:

9-2    695C.055  1.  The provisions of NRS 449.465, 679B.158, subsections

9-3  2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.025 to 680B.060,

9-4  inclusive, [and 695G.010 to 695G.260, inclusive,] chapter 695G of NRS

9-5  and section 16 of this act, apply to a health maintenance organization.

9-6    2.  For the purposes of subsection 1, unless the context requires that a

9-7  provision apply only to insurers, any reference in those sections to

9-8  “insurer” must be replaced by “health maintenance organization.”

9-9    Sec. 14.  NRS 695C.125 is hereby amended to read as follows:

9-10    695C.125  A health maintenance organization [may] shall not charge a

9-11  provider of health care a fee to include the name of the provider on a list of

9-12  providers of health care given by the health maintenance organization to its

9-13  enrollees. [The amount of the fee must be reasonable and must not exceed

9-14  an amount that is directly related to the administrative costs of the health

9-15  maintenance organization to include the provider on the list.]

9-16    Sec. 15.  NRS 695C.185 is hereby amended to read as follows:

9-17    695C.185  1.  Except as otherwise provided in subsection 2, a health

9-18  maintenance organization shall approve or deny a claim relating to a health

9-19  care plan within 30 days after the health maintenance organization receives

9-20  the claim. If the claim is approved, the health maintenance organization

9-21  shall pay the claim within 30 days after it is approved. [If] Except as

9-22  otherwise provided in this section, if the approved claim is not paid within

9-23  that period, the health maintenance organization shall pay interest on the

9-24  claim at [the] a rate of interest [established pursuant to NRS 99.040 unless

9-25  a different rate of interest is established pursuant to an express written

9-26  contract between the health maintenance organization and the provider of

9-27  health care.] equal to the prime rate at the largest bank in Nevada, as

9-28  ascertained by the commissioner of financial institutions, on January 1

9-29  or July 1, as the case may be, immediately preceding the date on which

9-30  the payment was due, plus 6 percent. The interest must be calculated from

9-31  30 days after the date on which the claim is approved until the date on

9-32  which the claim is paid.

9-33    2.  If the health maintenance organization requires additional

9-34  information to determine whether to approve or deny the claim, it shall

9-35  notify the claimant of its request for the additional information within 20

9-36  days after it receives the claim. The health maintenance organization shall

9-37  notify the provider of health care services of all the specific reasons for the

9-38  delay in approving or denying the claim. The health maintenance

9-39  organization shall approve or deny the claim within 30 days after receiving

9-40  the additional information. If the claim is approved, the health maintenance

9-41  organization shall pay the claim within 30 days after it receives the

9-42  additional information. If the approved claim is not paid within that period,

9-43  the health maintenance organization shall pay interest on the claim in the

9-44  manner prescribed in subsection 1.

9-45    3.  A health maintenance organization shall not request a claimant to

9-46  resubmit information that the claimant has already provided to the health

9-47  maintenance organization, unless the health maintenance organization

9-48  provides a legitimate reason for the request and the purpose of the request

10-1  is not to delay the payment of the claim, harass the claimant or discourage

10-2  the filing of claims.

10-3    4.  A health maintenance organization shall not pay only part of a claim

10-4  that has been approved and is fully payable.

10-5    5.  A court shall award costs and reasonable attorney’s fees to the

10-6  prevailing party in an action brought pursuant to this section.

10-7    6.  The payment of interest provided for in this section for the late

10-8  payment of an approved claim may be waived only if the payment was

10-9  delayed because of an act of God or another cause beyond the control of

10-10  the health maintenance organization.

10-11  7.  The commissioner may require a health maintenance organization

10-12  to provide evidence which demonstrates that the health maintenance

10-13  organization has substantially complied with the requirements set forth

10-14  in this section, including, without limitation, payment within 30 days of

10-15  at least 95 percent of approved claims or at least 90 percent of the total

10-16  dollar amount for approved claims. If the commissioner determines that

10-17  a health maintenance organization is not in substantial compliance with

10-18  the requirements set forth in this section, the commissioner may require

10-19  the health maintenance organization to pay an administrative fine in an

10-20  amount to be determined by the commissioner.

10-21  Sec. 16.  Chapter 695G of NRS is hereby amended by adding thereto a

10-22  new section to read as follows:

10-23  A managed care organization that establishes a panel of providers of

10-24  health care for the purpose of offering health care services pursuant to

10-25  chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS shall not charge

10-26  a provider of health care a fee to include the name of the provider on the

10-27  panel of providers of health care.

10-28  Sec. 17.  Chapter 616C of NRS is hereby amended by adding thereto

10-29  the provisions set forth as sections 18 and 19 of this act.

10-30  Sec. 18. 1.  Except as otherwise provided in this section, an insurer

10-31  shall approve or deny a bill for accident benefits received from a provider

10-32  of health care within 30 calendar days after the insurer receives the bill.

10-33  If the bill for accident benefits is approved, the insurer shall pay the bill

10-34  within 30 calendar days after it is approved. Except as otherwise provided

10-35  in this section, if the approved bill for accident benefits is not paid within

10-36  that period, the insurer shall pay interest to the provider of health care at

10-37  a rate of interest equal to the prime rate at the largest bank in Nevada, as

10-38  ascertained by the commissioner of financial institutions, on January 1

10-39  or July 1, as the case may be, immediately preceding the date on which

10-40  the payment was due, plus 6 percent. The interest must be calculated

10-41  from 30 calendar days after the date on which the bill is approved until

10-42  the date on which the bill is paid.

10-43  2.  If an insurer needs additional information to determine whether to

10-44  approve or deny a bill for accident benefits received from a provider of

10-45  health care, he shall notify the provider of health care of his request for

10-46  the additional information within 20 calendar days after he receives the

10-47  bill. The insurer shall notify the provider of health care of all the specific

10-48  reasons for the delay in approving or denying the bill for accident

10-49  benefits. Upon the receipt of such a request, the provider of health care

11-1  shall furnish the additional information to the insurer within 20 calendar

11-2  days after receiving the request. If the provider of health care fails to

11-3  furnish the additional information within that period, the provider of

11-4  health care is not entitled to the payment of interest to which he would

11-5  otherwise be entitled for the late payment of the bill for accident benefits.

11-6  The insurer shall approve or deny the bill for accident benefits within 20

11-7  calendar days after he receives the additional information. If the bill for

11-8  accident benefits is approved, the insurer shall pay the bill within 20

11-9  calendar days after he receives the additional information. Except as

11-10  otherwise provided in this subsection, if the approved bill for accident

11-11  benefits is not paid within that period, the insurer shall pay interest to the

11-12  provider of health care at the rate set forth in subsection 1. The interest

11-13  must be calculated from 20 calendar days after the date on which the

11-14  insurer receives the additional information until the date on which the

11-15  bill is paid.

11-16  3.  An insurer shall not request a provider of health care to resubmit

11-17  information that the provider of health care has previously provided to

11-18  the insurer, unless the insurer provides a legitimate reason for the

11-19  request and the purpose of the request is not to delay the payment of the

11-20  accident benefits, harass the provider of health care or discourage the

11-21  filing of claims.

11-22  4.  An insurer shall not pay only a portion of a bill for accident

11-23  benefits that has been approved and is fully payable.

11-24  5.  The administrator may require an insurer to provide evidence

11-25  which demonstrates that the insurer has substantially complied with the

11-26  requirements of this section, including, without limitation, payment

11-27  within the time required of at least 95 percent of approved accident

11-28  benefits or at least 90 percent of the total dollar amount of approved

11-29  accident benefits. If the administrator determines that an insurer is not

11-30  in substantial compliance with the requirements of this section, the

11-31  administrator may require the insurer to pay an administrative fine in an

11-32  amount to be determined by the administrator.

11-33  6.  The payment of interest provided for in this section for the late

11-34  payment of an approved claim may be waived only if the payment was

11-35  delayed because of an act of God or another cause beyond the control of

11-36  the insurer.

11-37  7.  Payments made by an insurer pursuant to this section are not an

11-38  admission of liability for the accident benefits or any portion of the

11-39  accident benefits.

11-40  Sec. 19. 1.  If an insurer, organization for managed care or

11-41  employer who provides accident benefits for injured employees pursuant

11-42  to NRS 616C.265 denies payment for some or all of the services itemized

11-43  on a statement submitted by a provider of health care on the sole basis

11-44  that those services were not related to the employee’s industrial injury or

11-45  occupational disease, the insurer, organization for managed care or

11-46  employer shall, at the same time that it sends notification to the provider

11-47  of health care of the denial, send a copy of the statement to the injured

11-48  employee and notify the injured employee that it has denied payment.

11-49  The notification sent to the injured employee must:

12-1    (a) State the relevant amount requested as payment in the statement,

12-2  that the reason for denying payment is that the services were not related

12-3  to the industrial injury or occupational disease and that, pursuant to

12-4  subsection 2, the injured employee will be responsible for payment of the

12-5  relevant amount if he does not, in a timely manner, appeal the denial

12-6  pursuant to NRS 616C.305 and 616C.315 to 616C.385, inclusive, or

12-7  appeals but is not successful.

12-8    (b) Include an explanation of the injured employee’s right to request a

12-9  hearing to appeal the denial pursuant to NRS 616C.305 and 616C.315 to

12-10  616C.385, inclusive, and a suitable form for requesting a hearing to

12-11  appeal the denial.

12-12  2.  An injured employee who does not, in a timely manner, appeal the

12-13  denial of payment for the services rendered or who appeals the denial but

12-14  is not successful is responsible for payment of the relevant charges on

12-15  the itemized statement.

12-16  3.  To succeed on appeal, the injured employee must show that the:

12-17  (a) Services provided were related to the employee’s industrial injury

12-18  or occupational disease; or

12-19  (b) Insurer, organization for managed care or employer who provides

12-20  accident benefits for injured employees pursuant to NRS 616C.265 gave

12-21  prior authorization for the services rendered and did not withdraw that

12-22  prior authorization before the services of the provider of health care were

12-23  rendered.

12-24  Sec. 20. NRS 616C.065 is hereby amended to read as follows:

12-25  616C.065  1.  [Within] Except as otherwise provided in section 18 of

12-26  this act, within 30 days after the insurer has been notified of an industrial

12-27  accident, every insurer shall:

12-28  (a) Commence payment of a claim for compensation; or

12-29  (b) Deny the claim and notify the claimant and administrator that the

12-30  claim has been denied.

12-31  Payments made by an insurer pursuant to this section are not an admission

12-32  of liability for the claim or any portion of the claim.

12-33  2.  [If] Except as otherwise provided in this subsection, if an insurer

12-34  unreasonably delays or refuses to pay the claim within 30 days after the

12-35  insurer has been notified of an industrial accident, the insurer shall pay

12-36  upon order of the administrator an additional amount equal to three times

12-37  the amount specified in the order as refused or unreasonably delayed. This

12-38  payment is for the benefit of the claimant and must be paid to him with the

12-39  compensation assessed pursuant to chapters 616A to 617, inclusive, of

12-40  NRS. The provisions of this section do not apply to the payment of a bill

12-41  for accident benefits that is governed by the provisions of section 18 of

12-42  this act.

12-43  Sec. 21. NRS 616C.135 is hereby amended to read as follows:

12-44  616C.135  1.  A provider of health care who accepts a patient as a

12-45  referral for the treatment of an industrial injury or an occupational disease

12-46  may not charge the patient for any treatment related to the industrial injury

12-47  or occupational disease, but must charge the insurer. The provider of health

12-48  care may charge the patient for any [other unrelated services which are

13-1  requested in writing by the patient.] services that are not related to the

13-2  employee’s industrial injury or occupational disease.

13-3    2.  The insurer is liable for the charges for approved services related to

13-4  the industrial injury or occupational disease if the charges do not exceed:

13-5    (a) The fees established in accordance with NRS 616C.260 or the usual

13-6  fee charged by that person or institution, whichever is less; and

13-7    (b) The charges provided for by the contract between the provider of

13-8  health care and the insurer or the contract between the provider of health

13-9  care and the organization for managed care.

13-10  3.  If a provider of health care, an organization for managed care, an

13-11  insurer or an employer violates the provisions of this section, the

13-12  administrator shall impose an administrative fine of not more than $250 for

13-13  each violation.

13-14  Sec. 22.  NRS 616C.220 is hereby amended to read as follows:

13-15  616C.220  1.  The division shall designate one:

13-16  (a) Third-party administrator who has a valid certificate issued by the

13-17  commissioner pursuant to NRS 683A.085; or

13-18  (b) Insurer, other than a self-insured employer or association of self-

13-19  insured public or private employers,

13-20  to administer claims against the uninsured employers’ claim fund. The

13-21  designation must be made pursuant to reasonable competitive bidding

13-22  procedures established by the administrator.

13-23  2.  [An] Except as otherwise provided in this subsection, an employee

13-24  may receive compensation from the uninsured employers’ claim fund if:

13-25  (a) He was hired in this state or he is regularly employed in this state;

13-26  (b) He suffers an accident or injury [in this state] which arises out of

13-27  and in the course of his employment [;] :

13-28     (1) In this state; or

13-29     (2) While on temporary assignment outside the state for a period of

13-30  not more than 12 months;

13-31  (c) He files a claim for compensation with the division; and

13-32  (d) He makes an irrevocable assignment to the division of a right to be

13-33  subrogated to the rights of the injured employee pursuant to

13-34  NRS 616C.215.

13-35  An employee who suffers an accident or injury while on temporary

13-36  assignment outside the state is not eligible to receive compensation from

13-37  the uninsured employers’ claim fund unless he has been denied workers’

13-38  compensation in the state in which the accident or injury occurred.

13-39  3.  If the division receives a claim pursuant to subsection 2, the division

13-40  shall immediately notify the employer of the claim.

13-41  4.  For the purposes of this section, the employer has the burden of

13-42  proving that he provided mandatory industrial insurance coverage for the

13-43  employee or that he was not required to maintain industrial insurance for

13-44  the employee.

13-45  5.  Any employer who has failed to provide mandatory coverage

13-46  required by the provisions of chapters 616A to 616D, inclusive, of NRS is

13-47  liable for all payments made on his behalf, including any benefits,

13-48  administrative costs or attorney’s fees paid from the uninsured employers’

13-49  claim fund or incurred by the division.

14-1    6.  The division:

14-2    (a) May recover from the employer the payments made by the division

14-3  that are described in subsection 5 and any accrued interest by bringing a

14-4  civil action in district court.

14-5    (b) In any civil action brought against the employer, is not required to

14-6  prove that negligent conduct by the employer was the cause of the

14-7  employee’s injury.

14-8    (c) May enter into a contract with any person to assist in the collection

14-9  of any liability of an uninsured employer.

14-10  (d) In lieu of a civil action, may enter into an agreement or settlement

14-11  regarding the collection of any liability of an uninsured employer.

14-12  7.  The division shall:

14-13  (a) Determine whether the employer was insured within 30 days after

14-14  receiving notice of the claim from the employee.

14-15  (b) Assign the claim to the third-party administrator or insurer

14-16  designated pursuant to subsection 1 for administration and payment of

14-17  compensation.

14-18  Upon determining whether the claim is accepted or denied, the designated

14-19  third-party administrator or insurer shall notify the injured employee, the

14-20  named employer and the division of its determination.

14-21  8.  Upon demonstration of the:

14-22  (a) Costs incurred by the designated third-party administrator or insurer

14-23  to administer the claim or pay compensation to the injured employee; or

14-24  (b) Amount that the designated third-party administrator or insurer will

14-25  pay for administrative expenses or compensation to the injured employee

14-26  and that such amounts are justified by the circumstances of the

14-27  claim,

14-28  the division shall authorize payment from the uninsured employers’ claim

14-29  fund.

14-30  9.  Any party aggrieved by a determination regarding the

14-31  administration of an assigned claim or a determination made by the

14-32  division or by the designated third-party administrator or insurer regarding

14-33  any claim made pursuant to this section may appeal that determination

14-34  within 60 days after the determination is rendered to the hearings division

14-35  of the department of administration in the manner provided by NRS

14-36  616C.305 and 616C.315 to 616C.385, inclusive.

14-37  10.  All insurers shall bear a proportionate amount of a claim made

14-38  pursuant to chapters 616A to 616D, inclusive, of NRS, and are entitled to a

14-39  proportionate amount of any collection made pursuant to this section as an

14-40  offset against future liabilities.

14-41  11.  An uninsured employer is liable for the interest on any amount

14-42  paid on his claims from the uninsured employers’ claim fund. The interest

14-43  must be calculated at a rate equal to the prime rate at the largest bank in

14-44  Nevada, as ascertained by the commissioner of financial institutions, on

14-45  January 1 or July 1, as the case may be, immediately preceding the date of

14-46  the claim, plus 3 percent, compounded monthly, from the date the claim is

14-47  paid from the fund until payment is received by the division from the

14-48  employer.

15-1    12.  Attorney’s fees recoverable by the division pursuant to this section

15-2  must be:

15-3    (a) If a private attorney is retained by the division, paid at the usual and

15-4  customary rate for that attorney.

15-5    (b) If the attorney is an employee of the division, paid at the rate

15-6  established by regulations adopted by the division.

15-7  Any money collected must be deposited to the uninsured employers’ claim

15-8  fund.

15-9    13.  In addition to any other liabilities provided for in this section, the

15-10  administrator may impose an administrative fine of not more than $10,000

15-11  against an employer if the employer fails to provide mandatory coverage

15-12  required by the provisions of chapters 616A to 616D, inclusive, of NRS.

15-13  Sec. 23.  NRS 617.401 is hereby amended to read as follows:

15-14  617.401  1.  The division shall designate one:

15-15  (a) Third-party administrator who has a valid certificate issued by the

15-16  commissioner pursuant to NRS 683A.085; or

15-17  (b) Insurer, other than a self-insured employer or association of self-

15-18  insured public or private employers,

15-19  to administer claims against the uninsured employers’ claim fund. The

15-20  designation must be made pursuant to reasonable competitive bidding

15-21  procedures established by the administrator.

15-22  2.  [An] Except as otherwise provided in this subsection, an employee

15-23  may receive compensation from the uninsured employers’ claim fund if:

15-24  (a) He was hired in this state or he is regularly employed in this state;

15-25  (b) He contracts an occupational disease [as a result of work performed

15-26  in this state;] that arose out of and in the course of employment:

15-27     (1) In this state; or

15-28     (2) While on temporary assignment outside the state for a period of

15-29  not more than 12 months;

15-30  (c) He files a claim for compensation with the division; and

15-31  (d) He makes an irrevocable assignment to the division of a right to be

15-32  subrogated to the rights of the employee pursuant to NRS 616C.215.

15-33  An employee who contracts an occupational disease that arose out of and

15-34  in the course of employment while on temporary assignment outside the

15-35  state is not entitled to receive compensation from the uninsured

15-36  employers’ claim fund unless he has been denied workers’ compensation

15-37  in the state in which the disease was contracted.

15-38  3.  If the division receives a claim pursuant to subsection 2, the division

15-39  shall immediately notify the employer of the claim.

15-40  4.  For the purposes of this section, the employer has the burden of

15-41  proving that he provided mandatory coverage for occupational diseases for

15-42  the employee or that he was not required to maintain industrial insurance

15-43  for the employee.

15-44  5.  Any employer who has failed to provide mandatory coverage

15-45  required by the provisions of this chapter is liable for all payments made on

15-46  his behalf, including, but not limited to, any benefits, administrative costs

15-47  or attorney’s fees paid from the uninsured employers’ claim fund or

15-48  incurred by the division.

 

16-1    6.  The division:

16-2    (a) May recover from the employer the payments made by the division

16-3  that are described in subsection 5 and any accrued interest by bringing a

16-4  civil action in district court.

16-5    (b) In any civil action brought against the employer, is not required to

16-6  prove that negligent conduct by the employer was the cause of the

16-7  occupational disease.

16-8    (c) May enter into a contract with any person to assist in the collection

16-9  of any liability of an uninsured employer.

16-10  (d) In lieu of a civil action, may enter into an agreement or settlement

16-11  regarding the collection of any liability of an uninsured employer.

16-12  7.  The division shall:

16-13  (a) Determine whether the employer was insured within 30 days after

16-14  receiving the claim from the employee.

16-15  (b) Assign the claim to the third-party administrator or insurer

16-16  designated pursuant to subsection 1 for administration and payment of

16-17  compensation.

16-18  Upon determining whether the claim is accepted or denied, the designated

16-19  third-party administrator or insurer shall notify the injured employee, the

16-20  named employer and the division of its determination.

16-21  8.  Upon demonstration of the:

16-22  (a) Costs incurred by the designated third-party administrator or insurer

16-23  to administer the claim or pay compensation to the injured employee; or

16-24  (b) Amount that the designated third-party administrator or insurer will

16-25  pay for administrative expenses or compensation to the injured employee

16-26  and that such amounts are justified by the circumstances of the

16-27  claim,

16-28  the division shall authorize payment from the uninsured employers’ claim

16-29  fund.

16-30  9.  Any party aggrieved by a determination regarding the

16-31  administration of an assigned claim or a determination made by the

16-32  division or by the designated third-party administrator or insurer regarding

16-33  any claim made pursuant to this section may appeal that determination

16-34  within 60 days after the determination is rendered to the hearings division

16-35  of the department of administration in the manner provided by NRS

16-36  616C.305 and 616C.315 to 616C.385, inclusive.

16-37  10.  All insurers shall bear a proportionate amount of a claim made

16-38  pursuant to this chapter, and are entitled to a proportionate amount of any

16-39  collection made pursuant to this section as an offset against future

16-40  liabilities.

16-41  11.  An uninsured employer is liable for the interest on any amount

16-42  paid on his claims from the uninsured employers’ claim fund. The interest

16-43  must be calculated at a rate equal to the prime rate at the largest bank in

16-44  Nevada, as ascertained by the commissioner of financial institutions, on

16-45  January 1 or July 1, as the case may be, immediately preceding the date of

16-46  the claim, plus 3 percent, compounded monthly, from the date the claim is

16-47  paid from the fund until payment is received by the division from the

16-48  employer.

17-1    12.  Attorney’s fees recoverable by the division pursuant to this section

17-2  must be:

17-3    (a) If a private attorney is retained by the division, paid at the usual and

17-4  customary rate for that attorney.

17-5    (b) If the attorney is an employee of the division, paid at the rate

17-6  established by regulations adopted by the division.

17-7  Any money collected must be deposited to the uninsured employers’ claim

17-8  fund.

17-9    13.  In addition to any other liabilities provided for in this section, the

17-10  administrator may impose an administrative fine of not more than $10,000

17-11  against an employer if the employer fails to provide mandatory coverage

17-12  required by the provisions of this chapter.

17-13  Sec. 23.5.  Section 10 of Assembly Bill No. 338 of this session is

17-14  hereby amended to read as follows:

17-15     Sec. 10. NRS 616C.135 is hereby amended to read as follows:

17-16     616C.135  1.  A provider of health care who accepts a patient as

17-17  a referral for the treatment of an industrial injury or an occupational

17-18  disease may not charge the patient for any treatment related to the

17-19  industrial injury or occupational disease, but must charge the insurer.

17-20  The provider of health care may charge the patient for any services

17-21  that are not related to the employee’s industrial injury or occupational

17-22  disease.

17-23     2.  The insurer is liable for the charges for approved services

17-24  related to the industrial injury or occupational disease if the charges

17-25  do not exceed:

17-26     (a) The fees established in accordance with NRS 616C.260 or the

17-27  usual fee charged by that person or institution, whichever is less; and

17-28     (b) The charges provided for by the contract between the provider

17-29  of health care and the insurer or the contract between the provider of

17-30  health care and the organization for managed care.

17-31     3.  A provider of health care may accept payment from an

17-32  injured employee who is paying in protest pursuant to section 5 of

17-33  this act for treatment or other services that the injured employee

17-34  alleges are related to the industrial injury or occupational disease.

17-35     4.  If a provider of health care, an organization for managed care,

17-36  an insurer or an employer violates the provisions of this section, the

17-37  administrator shall impose an administrative fine of not more than

17-38  $250 for each violation.

17-39  Sec. 24.  If a different rate of interest has been established pursuant to

17-40  an express written contract between an administrator, insurer, carrier,

17-41  corporation or health maintenance organization and a provider of health

17-42  care, the amendatory provisions of sections 1.5, 3, 5, 7, 10, 11.3, 15 and 18

17-43  of this act, relating to the amount of interest that accrues if an approved

17-44  claim is not timely paid, apply only to contracts between the administrator,

17-45  insurer, carrier, corporation or health maintenance organization and the

17-46  provider of health care that are entered into or renewed on or after

17-47  October 1, 2001.

 

18-1    Sec. 25.  1.  This section, sections 1 to 11.7, inclusive, and 13 to 24,

18-2  inclusive, of this act become effective on October 1, 2001.

18-3    2.  Section 12 of this act becomes effective at 12:01 a.m. on October 1,

18-4  2001.

18-5  H